What is the treatment for pneumocephalus?

Treatment of Pneumocephalus

For most cases of pneumocephalus, conservative management with supplemental oxygen therapy and close monitoring is the appropriate initial approach, reserving urgent neurosurgical intervention for tension pneumocephalus causing mass effect or neurological deterioration. 1

Initial Assessment and Risk Stratification

The critical first step is distinguishing simple pneumocephalus from tension pneumocephalus, as this determines urgency of intervention:

• Simple pneumocephalus presents with headache, nausea, vomiting, or mild dizziness and typically resolves spontaneously over days 1, 2
• Tension pneumocephalus manifests with progressive neurological deterioration, depressed consciousness, seizures, or signs of cerebral herniation and constitutes a neurosurgical emergency 3, 1
• Obtain immediate CT or MRI imaging to quantify air volume and assess for mass effect 1
• Look specifically for the "Mount Fuji sign" on imaging, which indicates dangerous compression of frontal lobes 3

Conservative Management (First-Line for Simple Pneumocephalus)

Initiate 100% supplemental oxygen therapy immediately, as this significantly accelerates reabsorption of intracranial air by creating a favorable diffusion gradient. 1

• Position patient flat and supine to prevent air migration and reduce intracranial pressure 4
• Avoid nitrous oxide anesthesia completely, as it expands pneumocephalus volume 1
• Monitor neurological status every 2-4 hours initially, then daily once stable 1
• Repeat imaging if clinical deterioration occurs or symptoms persist beyond expected timeframe 1
• Most simple pneumocephalus resolves within days to 2 weeks with conservative measures alone 5, 1

Urgent Neurosurgical Intervention

Tension pneumocephalus requires immediate burr-hole evacuation or craniotomy to prevent cerebral herniation and death. 3

Absolute indications for emergency surgery include:

• Progressive neurological deterioration or altered consciousness 3, 1
• Signs of increased intracranial pressure or impending herniation 3
• Significant mass effect on brain parenchyma visible on imaging 1
• Seizures refractory to medical management 1, 2
• Delayed presentation (≥72 hours post-injury) with worsening symptoms 3

Surgical options:

• Burr-hole placement in the frontal region for rapid decompression is the initial procedure of choice 3
• Craniotomy with dural repair may be necessary if ongoing CSF leak or skull base defect identified 3, 2
• Address any underlying CSF fistula to prevent recurrence 5, 3

Special Considerations and Pitfalls

Do not delay neurosurgical consultation if tension pneumocephalus is suspected—this is a life-threatening emergency with mortality risk if untreated. 3

• Pneumocephalus can develop in delayed fashion (≥72 hours) after trauma or surgery, requiring sustained vigilance 3
• If air transport is necessary, fly at lowest possible altitude and maintain cabin pressurization to prevent expansion of intracranial air 4
• Consider gas-forming bacterial infection if pneumocephalus develops postoperatively without obvious dural breach 5
• High-flow nasal oxygen should be used with extreme caution in patients with suspected skull base fractures, as it can cause or worsen pneumocephalus 6
• The "ball valve" mechanism allows continuous air entry but prevents egress, creating progressive accumulation and tension 3, 1

Monitoring and Follow-Up

• Serial neurological examinations every 2-4 hours until clinically stable 1
• Repeat imaging only if clinical deterioration occurs, not routinely 1
• Most cases resolve within 2 weeks; persistence beyond this warrants investigation for ongoing CSF leak 5, 1
• Address underlying causes (skull base defects, CSF fistulas) to prevent recurrence 3, 2